"I don't go to funerals anymore": how people who use opioids grieve drug-related death in the US overdose epidemic.

BACKGROUND: Opioid-related overdose death is a public health epidemic in much of the USA, yet little is known about how people who use opioids (PWUO) experience overdose deaths in their social networks. We explore these experiences through a qualitative study of opioid-related overdose death bereavement among PWUO. METHODS: We recruited 30 adults who inject opioids from a syringe service program in the Midwestern USA and interviewed them using a semi-structured guide that addressed experiences of opioid use, opioid-related overdose, and overdose reversal via the medication naloxone. Interviews were transcribed verbatim and analyzed thematically. FINDINGS: Participants described overdose death as ever-present in their social worlds. Most (approximately 75%) reported at least one overdose death in their social network, and many came to consider death an inevitable end of opioid use. Participants described grief shaped by complex social relations and mourning that was interrupted due to involvement with social services and criminal legal systems. They also reported several ways that overdose deaths influenced their drug use, with some increasing their use and others adopting safer drug use practices. Despite the high prevalence of overdose deaths in their social networks, only one participant reported receiving grief support services. DISCUSSION: Findings underscore the need for interventions that not only maintain life, such as naloxone distribution, but also improve quality of life by attending to grief related to overdose death bereavement. We discuss policies and practices with the potential to address the unique psychological, social, and structural challenges of grief for this population.

"The coupons and stuff just made it possible": economic constraints and patient experiences of a produce prescription program.

Although produce prescription (PRx) programs have been shown to improve fruit and vegetable (FV) consumption, few studies have examined how economic constraints influence participant experience. We conducted a qualitative study of patient experience of a 3-month PRx program for hypertension (PRxHTN) including 3 safety-net clinics and 20 farmers' markets (FMs). We interviewed 23 PRxHTN participants using semistructured guides to understand their program experiences. Interviews were audio-taped, transcribed, and analyzed to identify a priori and emergent themes. PRxHTN participants completing qualitative interviews were mostly middle-aged (mean: 62 years) African American (100%) women (78%). Economic hardship as a barrier to maximum program participation and sustainability was a main theme identified, with three subthemes: (i) transportation issues shaped shopping and eating patterns and limited participant ability to access FMs to utilize PRxHTN vouchers; (ii) limited and unstable income shaped participant shopping and eating behavior before, during, and after PRxHTN; and (iii) participants emphasized individual-level influences like personal or perceived motivations for program participation, despite significant structural constraints, such as economic hardship, shaping their program engagement. Future PRx programs should bolster economic and institutional supports beyond FM vouchers such as transportation assistance, partnering with local food banks and expansion to local grocery stores offering year-round FV access to support sustained behavior change. Additionally, structural competency tools for providers may be warranted to reorient focus on structural influences on program engagement and away from potentially stigmatizing individual-level explanations for program success. These efforts have potential to enhance the translation of PRx programs to the needs of economically vulnerable patients who struggle to manage chronic illness and access basic nutrition.

"You Guys Really Care About Me ": a Qualitative Exploration of a Produce Prescription Program in Safety Net Clinics.

BACKGROUND: Although research shows produce prescription (PRx) programs increase fruit and vegetable (FV) consumption, little is known about how participants experience them. OBJECTIVE: To better understand how participants experience a PRx program for hypertensive adults at 3 safety net clinics partnered with 20 farmers' markets (FMs) in Cleveland, OH. DESIGN: We conducted semi-structured interviews with 5 program providers, 23 patient participants, and 2 FM managers. PARTICIPANTS: Patients interviewed were mainly middle-aged (mean age 62 years), African American (100%), and women (78%). Providers were mainly middle-aged men and women of diverse races/ethnicities. INTERVENTION: Healthcare providers enrolled adult patients who were food insecure and diagnosed with hypertension. Participating patients attended monthly clinic visits for 3 months. Each visit included a blood pressure (BP) check, dietary counseling for BP control, a produce prescription, and produce vouchers redeemable at local FMs. APPROACH: Patient interviews focused on (1) beliefs about food, healthy eating, and FMs; (2) clinic-based program experiences; and (3) FM experiences. Provider and market manager interviews focused on program provision. All interviews were audio-taped, transcribed, and analyzed thematically. KEY RESULTS: We identified four central themes. First, providers and patients reported positive interactions during program activities, but providers struggled to integrate the program into their workflow. Second, patients reported greater FV intake and FM shopping during the program. Third, social interactions enhanced program experience. Fourth, economic hardships influenced patient shopping and eating patterns, yet these hardships were minimized in some participants' views of patient deservingness for program inclusion. CONCLUSIONS: Our findings highlight promises and challenges of PRx programs for economically disadvantaged patients with a chronic condition. Patient participants reported improved interactions with providers, increased FV consumption, and incorporation of healthy eating into their social networks due to the program. Future efforts should focus on efficiently integrating PRx into clinic workflows, leveraging patient social networks, and including economic supports for maintenance of behavior change.

The psychotropic self/imaginary: subjectivity and psychopharmaceutical use among heroin users with co-occurring mental illness.

Many people diagnosed with mental illnesses struggle with illicit drug addiction. These individuals are often treated with psychiatric medications, yet little is known about how they experience this treatment. Research on the subjective experience of psychiatric medication use highlights the complex, contradictory, and ambiguous feelings often associated with this treatment. However, for those with mental illness and addiction, this experience is complicated by the need to manage both psychiatric medication and illicit drug use. Using ethnographic data from a study of heroin use in Northeast Ohio, we explore this experience by expanding the pharmaceutical self/imaginary (Jenkins, Pharmaceutical Self: The Global Shaping of Experience in an Age of Psychopharmacology, School for Advanced Research Press, Santa Fe, NM, 2010b) to include psychopharmaceuticals and illicit drugs, what we call the psychotropic self/imaginary. Through this lens we explore the ways participants interpret and manage their psychotropic drug use in relation to sociocultural, institutional, and political-economic contexts. This analysis reveals how participants seek desired effects of legally prescribed and illicit drugs to treat mental illness, manage heroin addiction, and maintain a perceived "normal" self. Participants manage their drug use using active strategies, such as selective use of psychiatric medications, in the context of structural constraints, such as restricted access to mental health care, and cultural contexts that blur distinctions between "good" medicines and "bad" drugs.

Does readiness to change predict reduced crack use in human immunodeficiency virus prevention?

This study examines crack cocaine (crack) use, readiness to change, and gender in a sample of 923 men and women randomized to standard human immunodeficiency virus (HIV) education (standard intervention [SI]) or peer-delivered intervention (enhanced intervention [EI]). Four levels of crack use characterized frequency of use in the past 30 days; readiness was assessed on three levels (precontemplation, contemplation, and preparation/action). Differences between intervention groups on crack use and readiness by gender were examined from baseline to 3-month follow-up. Overall, participants reduced their crack use from baseline, with those in the EI showing greater improvement than those in the SI. A small proportion of participants improved readiness; those who improved were more likely to improve their crack use. No significant gender differences were found. These findings suggest that the readiness construct does not fully capture the dynamics of change among out-of-treatment crack users. Further research is needed to fully comprehend the dynamics of change among this group.